


n* 






PERCUSSION OUTLINES. 



BY 



E. G. CUTLER, M. D. 



ASSISTANT IN PATHOLOGICAL ANATOMY, HARVARD MEDICAL SCHOOL; VISITING PHYSICIAN 

TO THE CARNEY HOSPITAL; PHYSICIAN TO OUT-PATIENTS, MASSACHUSETTS 

GENERAL HOSPITAL ; PATHOLOGIST TO THE CITY HOSPITAL , 



G. M. GARLAND, M. D. 



ASSISTANT IN CLINICAL MEDICINE, HARVARD MEDICAL SCHOOL; PROFESSOR OF THORACIC 

DISEASES, UNIVERSITY OF VERMONT ; VISITING PHYSICIAN TO THE CARNEY 

hospital: PHYSICIAN TO THE BOSTON DISPENSARY. 



•/ 






BOSTON: 
HOUGHTON, MIFFLIN AND COMPANY, 

11 EAST SEVENTEENTH STREET, NEW YORK. 

1882. 






.6 



Copyright, 1882, 
By E. G. CUTLER axd G. M. GARLAND 



The Riverside Press, Cambridge : 
Stereotyped and Printed by H. 0. Houghton & Co 



PEEFACE. 



This book is intended to teach students the ana- 
tomical position of the thoracic and abdominal viscera 
in the living subject, and to portray such boundaries of 
those organs as are accessible to percussion. The al- 
most daily necessity in every physician's practice for de- 
termining the position and size of some concealed organ 
will, we trust, prepare a cordial welcome for our book 
from those who prefer well-defined knowledge to un- 
certain guess-work. We have devoted our attention 
mainly to the normal condition, and what we say re- 
garding pathological phenomena is intended rather as a 
guide to the proper methods for detecting abnormal 
deviations than as a full description of the same. With 
regard to the preparation of the book we will add that 
it is essentially a condensed abstract of the German lit- 
erature upon this subject, as contributed by Weil, Fer- 
ber, Luschka, and Gerhardt. We have, however, re- 
peatedly and carefully reviewed, in our own practice and 
at the autopsy table, the points which we present, and 
have convinced ourselves that they are correct. 



CONTENTS. 



_ PAGE 

CHAPTER L 



Method in Peecubsion I 

CHAPTER IX 
The Sternum, Diaphragm, and Pleuba 8 

CHAPTER HX 
The Lungs 14 

CHAPTER IV. 
The Heart and the Pericardium 30 

CHAPTER V. 
The Liver 41 

CHAPTER VI. 
The Spleen 46 

CHAPTER VIL 
The Stomach 54 

CHAPTER VIIL 
The Kidneys 58 

CHAPTER IX. 
The Bladder . .60 

CHAPTER X 
The Uterus 62 

CHAPTER XL 
The Peritoneum $4 



PERCUSSION OUTLINES. 



CHAPTER I. 

METHOD IN PERCUSSION. 

The first essential to intelligent percussion is a cor- 
rect method. Much has been written about pleximeters 
of varied form and size — about hammers of different 
weight and material, but the secret of successful per- 
cussion lies in little details of method rather than in 
the fibre of any instrument. According to our own 
opinion the best pleximeter and hammer are the human 
finger. It is always available. It is never forgotten or 
lost. As a pleximeter it furnishes a wide scope in size, 
from its tip to its entire palmar surface, and it need 
never frighten the most timid child. It affords the best 
and most instantaneous information regarding the re- 
sistance of the parts percussed. The skillful use of the 
fingers is somewhat more difficult to acquire than that 
of a pleximeter and hammer, but any one who can per- 
cuss well with the fingers can also do well with instru- 
ments, although the reverse of this proposition is by no 
means true. 

It is a matter of choice whether one or more fingers 
be used on each hand. We always employ the last 
phalanx of the middle finger of the left hand as the 
pleximeter, while the other fingers are raised from the 
chest, so as not to interfere with the sound vibrations. 
l 



2 PERCUSSION OUTLINES. 

The rounded end of the middle finger of the right hand 
forms our hammer, and we strike the pleximeter just 
behind the nail in such a manner that the hammer nail 
shall not touch the skin of the underlying finger — that 
is, we strike with that fleshy part of the finger where the 
distal surface curves into the palmar. 

The pleximeter should be applied firmly with sufficient 
pressure to prevent the slipping about of the soft parts 
when the blow is given ; and this pressure should be 
uniform for the two sides of the chest. What is of 
still more importance, the percussion blows should be 
given with uniform force, especially when comparing op- 
posite sides of the chest. We have seen students un- 
able to demonstrate the most striking differences of 
percussion tones simply because they delivered their 
blows with constantly varying force. The relative mer- 
its of light and heavy percussion will be discussed later, 
but whether light or heavy, the blows must be uni- 
form. 

Again, in comparing two sides of a chest, one should 
always percuss symmetrical spots. If the pleximeter 
finger be laid upon a rib on the one side, it should not be 
transposed to an intercostal space on the other, but 
should be placed on the symmetrical point of the com- 
panion rib. 

Taking into careful account the correct use of the 
hands, attention should next be turned to the position 
of the patient. If the subject of percussion be a man, 
he should be exposed to the skin, due regard being paid 
to the temperature of the room. Our rule is as fol- 
lows : We tell a patient to strip to the waist and then 
to put on his coat. This leaves the front of the body 
bare and easily accessible. When we reach the axillary 
region one arm can be slipped out of its sleeve, and 
while the back is examined the coat can be put on in the 



METHOD IN PERCUSSION. 3 

reversed position. A similar amount of exposure is not 
usually advisable with women, but the judicious combi- 
nation of a thin undershirt and a shawl, or an unstarched 
dressing-sack alone, will allow ample scope for a skillful 
percussor. The patient should be told to sit quietly and 
naturally, with the chest muscles relaxed. Most men, 
when stripped and approached for percussion, will throw 
back their shoulders and protrude their chest as if on 
dress parade. The muscular tension thus produced will 
always modify the sounds from the organs beneath. 
The two sides of the body should be held symmetrically, 
and the face should be directed straight forward, in order 
that the sounds of the apices may not be obscured by 
tension of the overlying muscles. It is immaterial 
whether the hands hang at the side or are placed on 
top of the head. Hanging at the side, the arms are 
out of the way, except during percussion of the axillary 
regions. A slight withdrawal of the arm backward, how* 
ever, will give access to the anterior part of the axillary 
region, while a similar slight advance of the arm will 
expose the posterior part of the same space. If one 
hand is placed upon the head, which is on some accounts 
the most convenient position during percussion of the 
lower border of the lung, it should be remembered that 
such elevation of the arm carries the skin and ribs a 
trifle upward, and an allowance must be made for this 
deflection in the subsequent record of the border ob- 
tained. 

Patients should not stand during percussion. They 
should be allowed to sit on a stool or on a chair without 
arms. If the} 7 are too weak to sit up and we are obliged 
to percuss them in bed, we should be careful to note that 
the body is straight, and that the shoulders are squarely 
placed and not twisted out of symmetry by underlying 
bolsters or pillows. Reference should also be made to 



4 PERCUSSION OUTLINES. 

the fact that the position of the internal organs varies with 
changes in the position of the bodjv a point which will 
be treated of later under the head of the passive mo- 
bility of the percussion boundaries. 

Examination of the abdomen is best made with the 
subject lying upon the back, with the head slightly raised 
and the knees drawn up, so as to relax the abdominal 
wall. To expose the spleen, the subject should lie upon 
the right side, or half way between the right lateral and 
the prone position. 

Having thus discussed the preliminary stages of our 
task, we will now describe the manner in which an inter- 
nal organ may be outlined. It will be learned later that 
only a small portion of all the anatomical borders are 
accessible to percussion. Piorry, in the enthusiasm of a 
new study, claimed that every organ of the body emits a 
sound peculiar to, and distinctive of, itself. If this were 
true, all the internal organs might be mapped out with an- 
atomical nicety. Skoda was the first to vigorous^ attack 
this idea. He maintained that aerated organs are resonant 
by reason of the contained air. Those organs which con- 
tain no air are simply non-resonant, and the sounds which 
they emit when struck are indistinguishable from each 
other. The question of percussion outlines resolves itself 
into the tracing of boundaries between organs which are 
very resonant, and those which are less resonant or pos- 
sessed of a different quality of resonance, and those which 
are non-resonant. Thus it is easy to trace the boundary 
between the lung and the liver where they lie in appo- 
sition, but impossible to distinguish the line of contact 
between the heart and the liver. 

In order to define any border which comes within the 
province of our search we should percuss toward that 
border from either side — and alternately from both sides 
— in lines which are perpendicular to its known anatom- 



METHOD IN PERCUSSION. 5 

ical course. Inasmuch as most of the percussion boun- 
daries run transversely across the body, Ave have adopted 
the following series of perpendicular lines, which should 
be followed methodically and in succession: — 

•Sternal line .... Along the border of the sternum. 

Parasternal line . . Half way between the sternal and 
mainmillary lines. 

Mammillary line . . Through the nipple on the male. On 
the female this line should be drawn 
perpendicularly downward from about 
the middle of the clavicle. 

Anterior axillary line Along the anterior border of axilla. 

Axillary line . . . From the summit of the axilla down- 
wards. 

Posterior axillary line Along posterior border of axilla. 

Scapula line . . . Through the apex of the scapula when 
the arms are hanging at the sides. 

Vertebral line . . . Between the scapular and vertebral 
column. 

To illustrate the use of these lines, let us suppose that 
the lower border of the right lung is the object of inves- 
tigation. In such case one should begin on the sternal 
line, and percuss downward until a point is reached 
where the resonance of the lung ceases, and the flatness of 
the liver begins. Having repeated the percussion often 
enough to be sure of such change, this point should be 
designated by a pencil mark on the skin. Then the 
same steps should be repeated along the parasternal, 
mammillary, and anterior axillary lines, and so on to the 
vertebral line, the point of change of sound in each 
case being marked. Then if these points be connected 
by a continuous line, one will have a sketch of the lower 
border of the lung. It is always serviceable to percuss 
toward the border sought, not only from above down- 
ward, but also from below upward, in which case one 



6 PERCUSSION OUTLINES. 

would mark the points where flatness changes to reso- 
nance. 

In outlining the heart one should percuss in the 
sternal, parasternal, and mammillary lines, and even in 
the anterior axillar}' and axillary lines. Under normal 
conditions, the left border of the heart, as shown in 
Plate IV., curves downward and runs parallel with the 
mammillary line, hence, to define this border, it will be 
necessary to approach it in oblique lines from the left 
shoulder and left axillary region. 

It is difficult to find a good pencil for marking the skin. 
Ink spreads and dries slowly. Burnt cork is very good, 
but inconvenient to cany, and an ordinary lead pencil is 
too hard to make a mark on soft skin. Chalk and car- 
bon work well for a time, but they rapidly absorb oil 
from the skin, and cease to mark unless refreshed with 
sand paper. We have found a very convenient marker 
in the pencils which actresses use for staining their eye- 
lids. These pencils are made, like ordinary cosmetics, 
from grease stained with lamp-black or vermilion. They 
are put up in little tin cases, with slides for pushing them 
in and out, and can be carried about in the pocket. 
They can be obtained at any perfumery store. 

We must again emphasize the necessity of percussing 
in straight lines, and of carefully completing one line 
before beginning another. Students are very apt to 
percuss across the chest in a zigzag direction or wander 
about in circles. Such percussion teaches nothing, and 
only serves to confuse the examiner. 

A word in regard to the relative merits of light and 
heavy percussion. Undoubtedly heavy percussion has 
its place and serves a good purpose, especially over thick 
muscles on the back, and in bringing out the dullness 
of deep-seated consolidation. In outline percussion, 
however, on the lateral and anterior aspects of the body, 



METHOD IN PERCUSSION. 7 

light percussion alone should be employed. In crossing 
the boundary between a resonant and a non-resonant 
organ, if our blows are heavy, the resonance of the 
former organ will be so transmitted over the latter that 
the line of demarkation will apparently lie several cen- 
timeters away from its actual position. We have found 
that the best results are obtained with extremely light 
percussion. The blow should never be given from the 
elbow, but from the wrist or from the metacarpal joint 
of the hammer finger. Where the chest is at all tender, 
and especially in percussing children, we always keep the 
hand quiet, and deliver our blows with the finger alone. 

The burden of this book is the normal percussion 
outlines of the body, and we devote but relatively small 
space to pathological deviations. In presenting the sub- 
ject thus, we have been actuated by the conviction that 
perfect familiarity with the normal is the only true guide 
to the abnormal. One who has a systematic method of 
searching for the normal, and pursues that method rigor- 
ously in every case, will never fail to detect abnormal 
deviations. 



CHAPTER II. 

STERNUM. 

The sternum consists of the manubrium, corpus sterni, 
and the ensiform cartilage. It ordinarily lies in the me- 
dian line, opposite the vertebral column. Congenital 
and acquired deformities of either side of the chest will 
of course alter its position. With pleuritic effusions the 
sternum swings toward the affected side like a pendulum, 
the lower end traveling four to five centimeters, while 
the upper end moves only two centimeters. 

The manubrium is normally quite resonant — the 
sound is neither tympanitic nor vesicular, but has a qual- 
ity of its own. It may be rendered dull by an over- 
filling of the veins from valvular disease of the heart ; 
by aneurism of the arch of the aorta; by pericardial 
effusion, and by pus gravitating from abscesses in the 
neck. In the last-named case it is important to notice 
that the dullness does not extend below the manubrium, 
because the firm adhesion of the membranes of the ante- 
rior mediastinum deflect the gravitating pus into the pos- 
terior mediastinal space. 

The resonance of the sternum is clearest and loudest be- 
tween the second and fourth ribs. It is also clear between 
the fourth and sixth ribs, although it here crosses 
the heart, and is to a great extent in direct contact 
with that organ. It would seem that the sternum is an 
excellent conductor of sound from the neighboring lungs, 
and thus conceals the flatness of the underlying heart. 



ANATOMY. 



DIAPHRAGM. 



Anatomy. 

Viewed from above, the diaphragm presents a dome- 
like projection into each side of the thorax, with a nearly 
horizontal plane connecting the summits of the domes. 
The upper surface is somewhat elliptical in shape, the 
transverse diameter being the longest. The diaphragm 
consists of two parts, a tendinous portion — pars phre- 
nica — which forms the plane above, and a muscular, 
portion — pars costalis — which constitutes the sides of 
the domes. The muscular portion has a long line of 
attachment extending from the sternum along the bor- 
der of the ribs to the vertebral column. The sternal 
segment rises chiefly from the apex of the ensiform car- 
tilage, and is immediately lost in the tendinous layer. 
The costal segment begins with one serration from the 
seventh costal cartilage, and another from the outer por- 
tion of the eighth cartilage. On the ninth rib the ser- 
rations extend about a finger-breadth beyond the carti- 
lage, on to the costal bone. From here to the twelfth rib, 
the muscle is attached to the osseous parts and the inter- 
costal spaces. Its serrations also interdigitate with the 
corresponding projections of the transverse abdominal 
muscle. The vertebral segment takes its origin from the 
first four lumbar vertebra?. 

Starting from this long line of attachment, the pars 
costalis rises directly upward, and lies in contact with the 
chest wall for a distance which varies on different sides 
of the chest and with different phases of respiration. On 
reaching the lower border of the lung and the heart, it is 
reflected beneath those organs and becomes the pars 
phrenica. 

The summit of the diaphragm changes with every 



10 PERCUSSION OUTLINES. 

stage of respiration, but at the end of ordinary expiration 
it coincides on the right side with a horizontal line drawn 
through the sternal ends of the fifth pair of ribs, and it is 
a costal space lower on the left side. On the back it cor- 
responds to the ninth dorsal vertebra. 

Percussion of the Diaphragm. 

The position of the diaphragm cannot be defined by 
means of any sound or modification of resonance peculiar 
to itself. It is only b}^ comparing its anatomical rela- 
tions to other organs with the percussion boundaries of 
those organs that we are able to form any opinion con- 
cerning it. 

The most important points to determine, are : — 

1. The line of transition from the pars costalis to 
the pars phrenica. This corresponds to the lower border 
of the lung, and may therefore be deferred to the discus- 
sion of that border. 

2. The position of the dome. Gerhardt says it is idle 
to try to define the arch of the dome, owing to its dis- 
tance from the chest wall. "Weil and Ferber think it 
can be defined by strong percussion, but this is a difficult 
task, and usually we can determine the probable height 
of the diaphragm only by inference from the position of 
other organs. When the dome of the diaphragm is de 
pressed into the abdomen by a large pleuritic effusion, it 
becomes readily accessible to percussion, and may often 
be felt. 

PLEURA. 

Anatomy. 

The pleural membranes are divided into four parts, ac- 
cording . to the organs with which they are associated. 
These parts are : — 



ANATOMY. 11 

Pars pulmonis, which directly envelops the lung and 
cannot be detached from the same. 

Pars phrenica, which covers the diaphragm. 

Pars mediastinalis, which helps form the partition be- 
tween the two halves of the chest. 

Pars costalis, which lines the inner surface of the ribs, 
intercostal spaces, and a portion of the sternum. 

At the apex of the chest, behind the sternum and 
along the vertebral column, the pars costal is is reflected 
inward, to form the pars mediastinalis, and these lines of 
reflection constitute respectively the superior, anterior, 
and posterior borders of the pleural cavity. The inferior 
border of that cavity is formed by the reflection of the 
costal into the diaphragmatic layer, or pars phrenica. 
The most important of these borders, for percussion, arc 
the superior, anterior, and inferior. 

The superior borders coincide accurately with the su- 
perior borders of the lungs, and therefore require no sep- 
arate notice at this point. See description of lungs, 
page 14. 

The anterior borders start on either side at the articu- 
lation of the clavicles with the sternum, Plate I., A B, c D. 
They advance obliquely downward and inward, behind 
the manubrium, until they reach the level of the inner 
extremities of the second ribs, where they come into con- 
tact with each other. Thence they proceed together 
downward a little to the left of the median line, as far 
as the fourth pair of ribs, when they separate. The 
right border continues still downward, with a slight in- 
clination to the right, until it meets the inferior border of 
the right pleura, in the median line of the sternum, at the 
level of the sixth intercostal space. 

The left anterior border bends somewhat sharply to 
the left at the fourth rib, and crosses the cardiac area in 
an irregularly diagonal direction until it reaches the 



12 PERCUSSION OUTLINES. 

parasternal line in the sixth intercostal space. Here it 
sweeps in an easy curve across the seventh costal cartil- 
age, and is lost in the inferior border of the left pleura. 

The inferior borders of the pleurae convex downward 
on either side. The left one runs obliquely downward 
and outward from the outer third of the sixth or sev- 
enth costal cartilage to the bony portion of the twelfth 
rib behind. Its termination is about on a level with a 
horizontal line which halves the twelfth pair of ribs. 
In its course it crosses the bony end of the eighth rib 
in the mammillary line, and from there on it comes in 
contact only with the bony portion of the ribs. It 
reaches the tenth rib in the axillary line. The lowest 
point of the pleural cavity is sometimes close to the 
vertebral column and sometimes a little out from the 
same. It maybe as far out as the scapular line in some 
cases. 

The right inferior border runs from the median line 
of the sternum outward and downward along the sixth 
costal cartilage or the sixth intercostal space to the outer 
third of the seventh costal cartilage, whence it proceeds 
in nearly the same manner as on the left side. It is 
noticeable, however, that the pleural border on the 
left side is a trifle low T er than that on the right side, 
which harmonizes with the fact that the left lung is 
longer though smaller than the right one. 

The posterior borders of the pleurae form perpendicu- 
lar lines on either side of the vertebral column. 

Notice : 1. The inferior border of the pleura does 
not reach so low as the line of attachment of the dia- 
phragm, which runs along the costal arch from the ensi- 
form cartilage to the outer extremity of the twelfth rib. 
The diaphragm in this region is intimately attached to 
the ribs and intercostal spaces. 

2. A portion of the pericardium has no pleural cover- 



ANATOMY. 13 

ing, owing to the oblique course of the anterior border of 
the left pleura. This exposed region has a triangular 
shape with its apex upward, and within this triangle the 
pericardium lies in direct contact with the chest wall. 
The portion of the pleura {pleura pericardiac a) which 
does overlie the pericardium is intimately attached to the 
latter. 

3. The anterior borders of the pleurae touch each other 
only between the second and fourth pair of ribs, and it 
is here only that the posterior surface of the sternum is 
wholly covered by pleura. 

4. A triangular space behind the upper part of the 
manubrium is free from pleural covering. Certain im- 
portant organs lie behind this space. A needle thrust 
through the manubrium at the angle formed by the 
pleural layers would pierce the upper part of the peri- 
cardium, which rises as high as the first pair of ribs. 
Above the pericardium one would wound first the vena 
innominata, and, back of that, the aorta. In childhood 
this space also contains the large thymus gland. 



CHAPTER III. 

LUNGS. 

Anatomy. — The lungs present three surfaces and five 
borders for consideration. The external or costal sur- 
face is convex outward, corresponding to the concavity 
of the chest wall, and it is a sort of spherical triangle 
with its apex above, and the lower pulmonary border for 
the base. The inferior surface is also a spherical triangle 
with its concavity looking down upon the diaphragm. 
The median or mediastinal surface looks toward the cen- 
tre of the body, and is pierced by the trachea and blood- 
vessels which administer to the functions of the lungs. 

Pulmonary Borders. — The superior border passes yoke- 
like over the shoulder at three to five centimeters (two 
to three finger-breadths) above the clavicle. Plate IV., 
G, H. Anteriorly, it runs close to, and parallel with, the 
posterior border of the sterno-cleido-mastoid muscle, until 
it reaches the sterno-clavicular articulation, when it be- 
comes the anterior border. On the back it is slightly 
concave upward, and terminates at the level of the spi- 
nous process of the seventh cervical vertebra. Plate 
VII., A B. 

The anterior border of the right lung corresponds accu- 
rately to the anterior border of the right pleura, as given 
on page 11, Plate I. 

The anterior border of the left lung runs also parallel 
with its pleura, as far as the inner extremity of the fourth 
rib. Here it bends sharply to the left, and lies along the 



LUNGS. 



15 



fourth costal cartilage as far as the parasternal line. Then 
descending slightly across the fourth intercostal space, it 
turns again toward the median line in a half-moon curve — 
Incisura cardiaca — and approaches the sternum until it 
reaches the sixth costal cartilage, when it again bends to the 
left and is lost in the inferior border. This peculiar deflec- 
tion of the border produces a tongue-like projection — 
lingula pulmonis — which overlies the apex of the heart. 
The inferior border of the left lung is, in front, a 
little lower than that of the right lung. This difference 
amounts to one and a half centimeters between the mam- 
millary and parasternal lines, but no perceptible differ- 
ence exists on the back. The following table shows the 
relative positions of the inferior border on the two 
sides. 



Parasternal and mammillary 

lines 
Axillary line .... 
Scapular line .... 
Vertebral line .... 



Upper border of 6th 
rib. 
Crosses 7th rib. 
Crosses 10th rib. 
Crosses 11th rib. 



Lower border 

6th rib. 
Crosses 7th rib. 
Crosses 1 0th rib. 
Crosses 11th rib. 



of 



This table represents the position of the borders at the 
end of normal expiration. The respiratory modifications 
of the same will be noted later. 

The posterior borders run parallel with the vertebral 
column. Little or no information can be obtained re- 
garding them by percussion, except in cases of pleurisy, 
when we find them shortened by the general contraction 
of the lungs. 

The antero-posterior borders, which bound the lower 
part of the mediastinal surfaces, are inaccessible to per- 
cussion. 

Incisurce Interlobular 'es. — Each lung is divided into 
lobes by incisure, which extend from the surface to the 
root of the lung, and are lined by reflections of the 



16 PERCUSSION OUTLINES. 

visceral pleura. The right lung has three lobes, the left 
lung two. 

The main incisura begins on either side, behind, at the 
level of the spinous process of the third dorsal vertebra. 
This also coincides with the spines of the scapulae, when 
the arms hang at the sides. 

On the left side, the incisura runs obliquely downward 
and forward, so as to cross the fourth rib in the axillary 
line, and ends in the lower border of the lung on the sixth 
rib in the mammillary line. Plate II., E D. 

On the right side the incisura divides into two 
branches, about five to six centimeters above the apex 
of the scapula. The upper branch runs forward, with 
very slight descent, and ends in the anterior border of 
the right lung at the fourth or fifth costal cartilage. In 
the mammillary line it stands at the level of the third 
rib. 

The lower branch runs obliquely downward and for- 
ward until it reaches the inferior border of the lung at the 
sixth costal cartilage near the mammillary line. These 
incisurse cannot be defined by percussion, except in cases 
of lobar infiltration of pneumonia. 

Notice : 1. In the position of ordinary expiration, the 
lower border of the lung on either side does not reach to 
the bottom of the pleural cavity, but is elevated above the 
same by a distance varying on different sides of the 
chest. Plate II. During inspiration the lung descends 
until, with the fullest breath, it occupies the entire cavity. 
With the following expiration, the lower border glides 
upward to resume its former position. The space which 
is thus alternately occupied and abandoned by the lung 
is called the complemented space (Gerhardt), or the 
sinus phrenico-costalis (Weil). As the lung deserts this 
space, the diaphragmatic and costal layers of the pleura 
are brought into contact, and thus the space becomes 
temporarily obliterated. 



LUNGS. 



17 



The variations in the depth of this space on different 
sides of the chest are shown in the following table 
(Weil): — 





RIGHT SIDE. 


LEFT SIDE. 


Parasternal line 
Mammillary line 
Axillary line .... 
Scapular line .... 
Vertebral line .... 


2£ ctm. 

6 " 

10 " 

4 to 5 " 

4 to 5 " 


3 ctm. 

6 " 

10 " 

4 to 5 " 

4 to 5 " 



These figures represent the condition of ordinary expi- 
ration. With forced expiration they may be much in- 
creased. 

2. The anterior border of the left lung, in the cardiac 
region, does not occupy the whole of the space allotted to 
it. Plate I., Q. This excess of room, reserved for the 
play of the pulmonary border, is called the sinus me- 
diastino- co stalls, and it will be seen later that the recog- 
nition of its condition is very important, especially for 
the diagnosis of emphysema. The widest portion of this 
sinus. is in the fourth intercostal space, where it is over 
three centimeters. 

3. The apex of the heart does not touch the chest wall, 
but is separated from the same by the lingula pulmonis. 

4. The lowest point of the lung is in the scapular line. 

PERCUSSION OF THE LUNGS. 

The only boundaries of the lungs which can be defined 
by percussion are the superior and inferior borders, and 
so much of the left anterior border as lies across the 
cardiac area. 

Superior Borders. — The apex of the lung rises above 
the clavicle from three to five centimeters. The su- 
perior border extends from the inner end of 'the clavi- 
cle, at first upward along the posterior edge of the 
sterno-cleido-mastoid muscle, and then over the shoulder 



18 PERCUSSION OUTLINES. 

in a gentle sweep, to the spinous process of the seventh 
cervical vertebra. Plate VII., A B. On the back, these 
borders concave upward. 

The distinction between the pulmonic resonance of 
the apex and the tympanitic resonance of the trachea 
in front can best be made out by light percussion, and 
with the patient's mouth open. The importance of de- 
termining these boundaries may be noticed in phthisis, 
when one apex is often found considerably retracted. 
Plate VII., O P. 

Anterior Borders. — Owing to the peculiar resonance 
of the sternum and to the fact that we cannot dis- 
tinguish the sound of the right from that of the left 
lung, it is impossible to outline those portions of the 
anterior borders which underlie the sternum. Plate 
IV. 

In percussing down the left sternal line, we notice a 
dulling of the resonance at the third rib. This dullness 
is due to the underlying heart, and will be further men- 
tioned in connection with that organ. On reaching the 
fourth rib there is a sudden change from pulmonary 
resonance to flatness, which indicates the transition from 
lung to heart. The line of this transition extends a short 
distance outward along the fourth rib, and then turns 
perpendicularly downward across the fifth rib. At the 
sixth rib it turns again to the left, and is lost in the 
lower border. The line a to c, along the left edge of the 
sternum, indicates the change from cardiac flatness to 
sternal resonance. 

Inferior Borders. — On the left side the inferior per- 
cussion border lies as follows : — 

Axillary line At the eighth rib. 

Scapular line At the tenth rib. 

Vertebral line At the eleventh rib. 

The position of this border in the mammillary line is 



LUNGS. 10 

often difficult to establish, owing to the great resonance 
of the stomach beneath. Ordinarily, however, it is 
placed at the sixth rib. 

The inferior percussion border of the right lung stands 
as follows : — 

Median line At base of xiphoid cartilage. 

Parasternal and mammillary 

lines On sixth rib. Sometimes nearer 

the upper edge ; sometimes 
nearer the lower edge of the 
rib. 

Axillary line At the eighth rib. It may be 

found as high as the seventh 
intercostal space, or as low as 
the eighth intercostal space. 

Scapular line At tenth rib. 

Vertebral line At eleventh rib. 

The line, P Q, in Plate IV., represents the superior 
border of the hepatic dullness, which will be described 
elsewhere. 

It will be remembered that these percussion bounda- 
ries represent the normal expiratory position of the lung 
in an adult. In extreme youth and in old age these 
boundaries are differently situated. Plate IX. represents 
the senile type, and Plate VIII. the infantile type. Thus 
we see in children the pulmonary boundaries may be 
found from one half to a whole interspace higher than in 
an adult, while in old age they are the same distance 
lower. 

Moreover, during life the borders of the lungs are con- 
tinually changing position with each act of respiration, 
and with every change of the body. 

Active mobility of the lungs. — Concurrent with the acts 
of breathing, the inferior borders of the lungs are alter- 
nately descending and ascending, so that their percussion 



20 PERCUSSION OUTLINES. 

limits include a considerable space. The inspiratory de- 
scent of the lower border is ordinarily : — 

In the right parasternal line . . . 1£ to 2 centimeters. 
In the right mammillary line . . . 2 to 3 centimeters. 

In both axillary lines 3 to 4 centimeters. 

In both scapular lines 2 centimeters. 

(Weil.) 

With forced expiration, these borders will be retracted 
as far above their usual position, and even further than 
they are lowered by the fullest inspiration. The amount 
of excursion, therefore, between the position of fullest ex- 
piration and that of fullest inspiration is : — 

In the mammillary line 8£ centimeters. 

In the axillary line 01 centimeters. 

In the scapular line 7^ centimeters. 

That portion of the left anterior border which over- 
lies the heart also undergoes active movements during 
respiration. With inspiration this border is carried for- 
ward into the sinus mediastino-costalis, so as to greatly 
diminish the area of cardiac flatness. In some persons 
the advance may be so great as to almost obliterate the 
cardiac flatness. In a similar way, the area of flatness 
is noticeably increased during full expiration. 

Passive mobility of the lungs. — Gerhardt found that 
the pneumono-hepatic border, when a man lies on his 
back, is one to two centimeters lower than in the erect 
posture. When one turns on to the right side, the in- 
ferior border of the left lung descends by a distance equal 
to a full inspiration. The same is true of the lower 
right border, when one lies on the left side. These 
changes of position are called the passive mobility of the 
lungs, and it is important to bear them in mind when per- 
cussing an invalid in bed. 

The active and passive mobility of the lungs are usually 



LUNGS. 21 

diminished or entirely absent in cases of emphysema and 
pleurisy. In the former disease the lungs are perma- 
nently enlarged and incapable of retraction, while in 
pleurisy the lungs may be either permanently retracted, 
or so tied up by adhesions as to be held stationary. 

Notice : The diagram of percussion boundaries, Plate 
IV., does not portray any divisions between the lobes. 
This is because the resonance of contiguous lobes cannot 
be distinguished from each other under ordinary condi- 
tions. In cases of pneumonia, where one lobe is solidi- 
fied and its neighbor is not, the line of transition from 
the dullness of the former to the resonance of the latter 
will coincide with the anatomical sulcus. The careful 
delineation of these lines will often assist in removing 
doubts between pneumonia and pleurisy. 

PATHOLOGY. 

Pneumonia. — Pneumonia does not produce any 
marked change in the gross outlines of the lungs. It 
causes a diminution of the pulmonary resonance, how- 
ever, which varies in intensity and extent according to 
the amount and degree of infiltration. In catarrhal 
pneumonia, the dull area may be limited to a few lobules 
only, but it is usually impossible to accurately define the 
outline of such an area, because the transition from dull- 
ness to the resonance of neighboring lobules is very 
gradual. 

When an entire lobe is hepatized, as in croupous 
pneumonia, the percussion line of demarkation between 
the dull and the companion resonant lobe corresponds 
to the anatomical sulcus which separates them. It is 
important to remember that in some stages of pneumonia 
— in the beginning of lobular pneumonia, and during the 
resolving stage of croupous pneumonia — we may obtain 
a tympanitic resonance over the parts which are relaxed 
by disease. 



22 PERCUSSION OUTLINES. 

Cavities. — Taken by themselves alone, and judged 
by any or all of the signs which are peculiar to them- 
selves, pulmonic cavities are very difficult of diagnosis. 
It may be laid down as a safe rule, to start with, that 
such cavities possess no pathognomonic percussion signs. 

Several signs have been described, however, and more 
or less importance has been attributed to them by differ- 
ent writers ; and yet a careful analysis of the conditions 
under which they may occur will reveal their fallibility 
as indicators of cavities. These signs are : the cracked- 
pot sound, tympanitic resonance, Wintrich's variable- 
pitch, Gerhardt's variable-pitch, amphoric resonance. 

The cracked-pot sound is obtained by listening at the 
open mouth of the patient, while strong percussion is 
made upon the chest. It resembles the chinking of 
money, and may be imitated by clasping the hands loosely 
together and striking the back of one of them upon the 
knee. This sound may be obtained from the chest, how- 
ever, without the presence of a cavity, as with pleural ef- 
fusion, pneumonia, pneumo-pericardium, and even upon 
health) 7 persons. Thus, if we percuss the back of a 
screaming infant, or of a thin woman, we may produce the 
cracked-pot sound. 

Tympanitic Resonance. — The best observers unite in 
declaring that a cavity must be as large as a man's fist, 
superficially situated, and surrounded by a certain amount 
of indurated tissue, in order to give forth a tympanitic 
note. But tympanitic resonance occurs more often with- 
out cavities than with them, as with pleurisy and pneu- 
monia. Weil thinks that not more than ten per cent, of 
the cases of tympanitic resonance over the lungs are at- 
tributable to pulmonic cavities. This sign, therefore, has 
but little value in itself. It has gained a new impor- 
tance, however, by certain investigations made regarding 
its pitch under various conditions. 



LUNGS. 



23 



Wintrictis Variable-pitch. — ■ Wintrich observed that 
when a cavity gave forth tympanitic resonance, the pitch 
of this resonance could be raised by opening the mouth of 
the patient. In order to obtain this sign the cavity must 
connect with a free bronchus. Sometimes the sign will 
appear and then disappear, by reason of the plugging of 
the bronchus with secretion. In such cases an effort at 
coughing will clear the tube and restore the sign. A 
similar change of pitch on opening and closing the mouth 
may be noticed when percussing over relaxed pulmonary 
tissue, and also with the so-called Williams' tracheal tone. 
It follows, therefore, that other possibilities must be 
eliminated before this sign can decisively indicate a 
cavity. 

Gerhardt's Variable-pitch. — Gerhardt noticed that a 
cavity which is oval in shape and contains both fluid 



&§■*. 




Fi&Z. 




and air, as in Fig. 1, will give forth a tympanitic res- 
onance which will vary in pitch with changes in the 
position of the patient. Suppose the long diameter of 
the cavity (a b) to be in the longitudinal axis of the 
body, then the percussion note will have a higher pitch 
when the patient stands, and a lower pitch when he lies 
on his back, because the column of air (a e), above the 



24 PERCUSSION OUTLINES. 

fluid, is shorter in the former case (Fig. 1) than the 
column (a b) is in the latter (Fig. 2). 

Amphoric Resonance. — This is a rare phenomenon with 
cavities. In order for its production the cavity must 
have a certain size ; its inner surface must be smooth, 
and its walls must be of uniform consistency. Leich- 
tenstein says that this phenomenon -can often be detected 
by listening to the chest, while a second person per- 
cusses over the suspected cavity with a lead pencil upon 
an ivory pleximeter. This method, he says, will often 
reveal a cavity when all other tests have failed. 

To sum up regarding the above signs, it may be said 
that the cracked-pot sound and tympanitic resonance 
have nothing characteristic of a cavity. The amphoric 
resonance is more conclusive, and yet this sound may be 
obtained over bronchi and trachea. 

Wintrieh's variable-pitch is very dubious. Gerhardt's 
variable-pitch, when well marked, is perhaps the most 
reliable of all. Weil says that in all cases where the 
pitch was lower in the upright position, and higher on 
lying down, he found a cavity present. In cases where 
the pitch became higher on sitting up, he found a cavity 
present in all but one instance. 

Valuable evidence regarding the formation of a cavity 
may be obtained under the following circumstances. 
During a prolonged observation of a dull region on the 
chest, if the resonance suddenly becomes clearer, or less 
dull, with a tympanitic tinge, then we may suspect a 
cavity, especially if the change in resonance is accompa- 
nied by a sudden and profuse expectoration. 

As to the size and exact form of a cavity, almost no 
information can be obtained under any circumstances. 
Thus, amphoric resonance, when present, is usually asso- 
ciated with large cavities, but cases have occurred where 
it appeared with a small cavity which connected freely 
with a bronchus. 



EMPHYSEMA. 25 

Emphysema. — In emphysema the entire chest as- 
sumes permanently the position of inspiratory expansion, 
which varies in degree according to the duration and 
amount of the disease. 

Pulmonary Borders. — The inferior borders are the 
ones chiefly affected. They may descend as low as the 
seventh intercostal space, or the eighth rib in the mam- 
mi llary line ; the tenth rib in the axillary line ; the 
twelfth rib in the vertebral line. With moderate em- 
physema the sinkage of the border will of course be 
proportionally less. 

The cardiac border is advanced so as to occupy the 
cardio-mediastinal sinus. By this means the area of 
cardiac flatness becomes diminished to a narrow zone at 
the level of the sixth rib, or it may be entirely obliterated 
in excessive cases. 

It will be remembered that, in old age, the diaphragm, 
heart, and inferior borders of the lungs always stand 
at a lower level than in adult life. Hence, in diagnos- 
ing emphysema, one should always compare the amount 
of pulmonary expansion with the age of the patient. If 
the lower border in a person over sixty-five years of age 
reach no further than the seventh rib in the mammillary 
line, the condition is normal. 

Another sign of emphysema is the diminution or ab- 
sence of both the active and passive mobility of the infe- 
rior borders of the lungs. We have seen cases where the 
most energetic efforts at respiration, in various positions 
of the body, failed to change the percussion borders. 

The apices of the lungs are often raised to a higher 
elevation — five to six centimeters — above the clavi- 
cles, in which case the superior borders are correspond- 
ingly higher. 

Hepatic Boundaries. — The outlines of the liver are 
considerably changed in emphysema. The pneumono- 



26 PERCUSSION OUTLINES. 

hepatic border is always lower, and the apparent size of 
the liver will then depend upon its relation to the ex- 
panded lung. If the liver remains in its normal posi- 
tion, or nearly so, then the area of hepatic flatness will 
be necessarily diminished. On the other hand, if the 
liver be simultaneously depressed by a descent of the dia- 
phragm, then the area of flatness may remain normal in 
size or even appear increased. 

Pleueisy. — The changes produced by pleurisy in the 
percussion boundaries of the lungs will vary according 
to the character, seat, and extent of the affection. A 
simple dry pleurisy with adhesions may leave the pul- 
monar} 7 boundaries little affected, except as regards their 
mobilit}'. Thus firm adhesions may interfere with the 
respiratory expansion, and also with the passive move- 
ments which normally accompany changes of the position 
of the body. Again, thick deposits of pleuritic mem- 
branes will produce a general diminution of vesicular 
resonance. 

Pleurisy with Effusion. — With an encysted pleuritic 
effusion, an area of dullness (or flatness, with a large 
amount of fluid) will be found, which varies in shape and 
position according to the size and situation of the exuda- 
tion. No general law can be laid down for such cases, 
and the dullness thus observed must be distinguished from 
that which accompanies consolidation of the lung, by 
such other evidence as can be obtained through auscul- 
tation and palpation. 

An accumulation of free fluid in the pleural cavity (pleu 
ritic effusion, empyema, hydrothorax, hsematothorax,) 
causes marked changes in the percussion outlines of the 
pulmonary borders. As the fluid gradually forms, it 
gathers at the bottom of the chest, and the lung begins 
to contract in volume. Let it be said here, that a lung 
which retains its integrity and elasticity cannot be pressed 



EMPHYSEMA. 27 

upon, or compressed by, an encroaching effusion, until it 
is completely collapsed, and the amount of fluid present, 
is excessive. The lung simply contracts in volume, but 
it still sustains the weight of the diaphragm plus that of 
the fluid in the same manner that it previously sustained 
the diaphragm alone. 

As soon as sufficient effusion has collected for detec- 
tion by percussion — 200 cc. according to Seitz — we 
obtain over the fluid a flat sound, and varying degrees of 
dullness over the collapsing lung above. The line of de- 
markation between the flatness of the fluid and the dull 
resonance of the lung is usually well marked. The 
shape and position of this line, however, have been the 
subject of much controversy. Most German writers fol- 
low Wintrich in declaring that this line stands generally 
highest behind in the neighborhood of the spinal column, 
and thence descends obliquely to the sternum. Some 
allow that the line may sometimes be horizontal, but they 
think that this shape is exceptional, and due to the posi- 
tion maintained by the patient during the early stage 
of the effusion. Thus, if the patient lie quietty in bed 
during that stage, the fluid will assume a level corre- 
sponding to that position. Subsequently, as the patient 
arises and walks about, the fluid is prevented from re- 
accommodation by adhesions, and hence the obliquity of 
its surface. Among the French, Piorry and his followers 
teach that an effusion ordinarily adjusts itself to a hori- 
zontal level for all positions of the body. On the other 
hand, Damoiseau declared that the line in question is 
never horizontal, but is more or less parabolic with its 
summit in the axillar}^ line, and its branches extending 
down on either side to the sternum and vertebral column. 

In our own experience, we have never seen a pleural 
effusion (pneumo-hydrothorax excepted) which presented 
a horizontal line of demarcation, nor do we obtain a line 



28 PERCUSSION OUTLINES. 

like that described by the Germans. On the contrary, 
we find that the position assumed by an effusion is that 
which was first described by Prof. Calvin Ellis, of Boston. 
This observer discovered that with small and medium 
effusions the line of flatness begins lowest behind at the 
vertebral column. Thence it ascends obliquely across the 
back, in a letter S curve, to the axillary region, where it 
reaches its highest point. Then it advances to the ster- 
num with a slight inclination downward. With large 
effusions, which fill the chest to the second rib or higher, 
this curve disappears, and the line becomes more nearly 
horizontal, and more difficult to trace. As absorption 
takes place, however, or the fluid is removed by aspira- 
tion, the curve reappears and passes through retrograde 
phases corresponding in shape to those of the earlier 
stages. 

It is sometimes difficult to trace the curve on the 
back, owing to the great dullness of the lung immediately 
above the effusion. This dullness is often due to a lack 
of proper ventilation of the lower lobe, especially when 
the patient is lying down, and therefore one should not 
attempt to trace the line until the patient has taken 
several deep breaths and thus thoroughly filled the lung. 
In Fig. III. it will be seen that we have drawn a hori- 
zontal line, A B, from the summit of the curve to the 
vertebral column, and have thereby inclosed a rough, 
triangular space, ABC. This space corresponds to 
the lowest portion of the lung, and is especially liable to 
be obscured by dullness. The lung lies here in contact 
with the chest wall, but its resonance may be so dull 
as to escape detection unless careful percussion is made 
and the patient breathes deeply. We have termed this 
space the dull triangle,, and its recognition is of vital 
importance. Heitler, in Vienna, has observed this same 
triangular space of resonance, and has likened it to a 



PLEURISY. 



29 



monk's hood cut longitudinally through the centre and 
hanging apex down. Rosenbach, of Breslau, has also 
noticed that the resonance of this portion of the back in 
pleurisy will often clear up on exercise or by breathing, 
and such clearing up of the resonance of a dull back he 



Fig 3. 








V/,'-\ v«%~. -> N \v.; 



has made distinctive between pleurisy and pneumonia. 
The same condition of things obtains in hydro thorax, but 
in some cases the triangle may be still more dull, and re- 
quire careful auscultation and percussion, owing to the 
oedema of the lung itself. 



CHAPTER IV. 

HEART. 

Anatomy. — The heart, inclosed in the pericardial sac, 
lies in an oblique plane extending from the right side 
above downward and forward toward the left side. It 
is situated partly behind the sternum and partly behind 
the right and left costal cartilages. Its highest point, 
the upper border of the left auricle, corresponds to a line 
connecting the lower borders of the sternal insertion of 
the second pair of ribs. Its lowest point is at the middle 
of the upper border of the sixth left costal cartilage. 
The heart extends eight or nine centimeters to the left, 
and four or five centimeters to the right, of the middle 
line of the sternum. We distinguish in the heart in 
relation to the chest wall, a right, a lower, and a left 
border. The right border (Plate I., M n) is formed by 
the right auricle, and runs in a line curving outward two 
to three centimeters beyond the right edge of the ster- 
num, from the middle of the second right intercostal 
space to behind the sternal end of the fifth right costal 
cartilage. 

The lower border N o, is formed by the right ventricle, 
and extends from the sternal end of the fifth right costal 
cartilage in a slightly descending line to the fifth left in- 
tercostal space, where it meets with the left border in the 
mammillary line, or a trifle inside it. 

The left border P o, runs in a convex curve from the 
second left intercostal space downward and outward to 



HEART. 31 

unite with the left end of the lower border at the apex of 
the heart. 

By far the greater portion of the heart is covered by 
lung ; only a segment of the organ belonging exclu- 
sively to the right ventricle lies directly against the 
chest wall ; this segment is bounded below by the lower 
edge of the heart, and on the right and left by the di- 
verging anterior borders of the right and left lung. 
The size and shape of this parietal portion of the heart 
depends wholly on the course of the anterior edges of the 
lungs, which have been fully described elsewhere. Dur- 
ing quiet respiration it has a four-sided shape (Plate I.). 
The right border is bounded by the front edge of the 
right lung running near the left border of the sternum 
from the level of the fourth to the sixth (or seventh) 
costal cartilage ; the upper border is bounded by that 
part of the incisura cardiaca behind the fourth left costal 
cartilage running outward to the fourth intercostal space ; 
the outer side is bounded by the more vertical portion of 
the anterior border of the left lung, running in a convex 
curve outward from the fourth intercostal space to the 
sixth rib. The upper and outer borders unite with no 
sharp line of division between them, and even in quiet 
respiration exhibit manifold differences in their course. 
This uncovered space is crossed diagonally .by the left 
pleura, in such a way that only in the lower portion does 
the pericardium come in actual contact with the sternum. 

PEBCUSSION. 

The heart gives forth a flat sound where it lies directly 
against the chest wall. The boundaries of this region of 
flatness above, to the right and left follow in general the 
course of the anterior edges of the lungs, and correspond 
to those lines in which the transition from the clear ve- 
sicular sound to the flat sound occurs. The lower border 



32 PERCUSSION OUTLINES. 

of the heart cannot be defined by percussion, because 
the flat sound of the heart is indistinguishable from that 
of the left lobe of the liver. The lower border, therefore, 
from the point where the liver meets it to the apex of the 
heart, must be drawn arbitrarily, as described later. 

We recognize an area of absolute flatness and one of 
relative dullness in the percussion of the heart. It is 
perhaps unnecessary to add that there are great diversities 
of opinion in regard to the size and shape of this abso- 
lute flatness, but we have generally found the following 
dimensions to be most nearly correct. 

In adults, the absolute cardiac flatness is an irregular 
quadrangle (Plate IV., ABCD). The right border A C is 
formed by the left edge of the sternum from the level of 
the fourth to the sixth or seventh rib ; the upper border 
A B runs behind the fourth costal cartilage outward and 
downward, and meets with the left side of the quadrangle 
at an obtuse angle ; the latter, B D, runs more vertically 
downward to the sixth rib, where it meets with the lower 
side of the quadrangle, C D, at an acute angle. While the 
inner and lower sides have a tolerably constant length, 
and, as a rule, measure five to six centimeters, the upper 
and outer sides show manifold differences in their course 
which it appears superfluous to mention in detail. We 
need only say, that when the upper side deviates more 
from a horizontal course, or the outer side becomes less 
vertical in its direction, the region of absolute flatness 
becomes smaller, and its form more triangular. The 
right, the upper, and the left borders of this space are 
readily obtained by gentle percussion. As the lower 
border, in the greater part of its course, overlies the left 
lobe of the liver, we can only obtain it by determining 
the point on the right, where the cardiac and hepatic 
flatness meet, and the position of the apex, and then join 
these two by a straight line. It is only in rare instances 



HEART. 33 

that the heart extends beyond the left lobe of the liver, 
and in such cases the cardiac flatness is bounded by the 
tympanitic sound of the stomach. 

Notice: Comparison of the absolute cardiac flatness 
and the portion of heart uncovered by lung shows a dif- 
ference only in two places. (1.) The right border of the 
cardiac flatness lies at the left edge of the sternum, the 
front edge of the right lung on the other hand is half way 
to the right of this line ; the cause of this difference is 
the oft mentioned vibration of the sternum. (2.) The 
thin lingula pulmonis overlying the cardiac apex cannot 
be mapped out. 

The shape of the heart's flatness, described and fig- 
ured in Plate IV., A B c D, is normal for healthy people 
from the middle of the second to the end of the sixth 
decade. In childhood, and also in old age, the shape and 
size of this area is somewhat different. In children, the 
absolute flatness of the heart begins at the third rib, and 
extends to the mammillary line (Plate VIII.), the apex 
impulse being frequently met with in the fourth intercos- 
tal space. The absolute cardiac flatness in children, there- 
fore, is found to be relatively greater and situated higher 
up than in middle age. In old age, on the other hand, 
the opposite condition is observed (Plate IX.). Here the 
area of cardiac flatness is smaller, it does not begin till 
we get to the fifth rib, and it reaches outward to a less 
extent ; its height and breadth amount to about four or 
five centimeters. The cause of this diminution in the 
size of the absolute flatness is the entrance of the border 
of the left lung into the sinus-mediastino-costalis depend- 
ent on senile emphysema, which may be regarded as a 
normal senile condition. We need hardly call special at- 
tention to the fact that these three types of cardiac flat- 
ness given for childhood, adult life, and old age, are not 
sharply defined, but rather gradually run into each other. 



34 PERCUSSION OUTLINES. 

Active Mobility of the Absolute Cardiac Flatness. 

The boundaries of absolute flatness are found in the 
shape and extent described above, when the person exam- 
ined maintains the dorsal decubitus and breathes nat- 
urally. These boundaries, however, suffer certain respi- 
ratory displacements, and also certain displacements in 
changes of the position of the body ; in other words, 
they have a considerable active and passive mobility. 

The upper border descends two to three centimeters, the 
left border moves about as much to the right, and the 
right border remains unchanged ; so that the absolute 
cardiac flatness is diminished perhaps one third. With 
the deepest possible .inspiration, only a strip of flatness 
the breadth of the finger can be discovered close to the 
sternum, or it may be replaced by a clear pulmonary res- 
onance at the left edge of the sternum. 

The expiratory displacement of the borders averages 
two centimeters outward and as much upward. 

Passive Mobility, 

When the individual examined changes from the 
dorsal decubitus to the upright position, no displacement 
of the cardiac boundaries follows. On the other hand, 
when one is in the right lateral decubitus the same effect 
is observed on the left and upper boundaries as in the 
deepest possible inspiration ; and very frequently a re- 
gion of flatness is found on the right of the sternum, 
between it and the parasternal line, at the level of the 
fifth or sixth rib, and even as high as the fourth intercos- 
tal space. This right-sided absolute cardiac flatness is 
separated from that on the left side by the clear sound 
of the sternum ; and it may be enlarged by forced ex- 
piration. The change from the dorsal to the left lateral 
decubitus involves an excursion of the upper and left 



HEART. 35 

borders in the same way : the left border, however, moves 
somewhat further toward the left than in forced expira- 
tion. 

Relative Cardiac Dullness. 

The size and shape of the relative dullness of the heart, 
that is, where it is overlaid by lung, in most healthy in- 
dividuals between the middle of the second and the end 
of the sixth decade is represented by the line A I K, 
Plate IV. 

The right border of the figure is formed by the left 
edge of the sternum from the level of the third to the 
sixth intercostal space. 

Above and toward the left the dullness is shut in by a 
curved line, with its convexity directed outward, I k. 
The upper more horizontal portion of this curve runs 
through the third intercostal space, and over the fourth 
rib obliquely outward and downward. The lower outer 
portion of the curve runs in a nearly vertical line from the 
fourth intercostal space to the sixth rib, just inside the 
mammillary line. 

Notice : 1. The percussion boundary corresponds to 
the anatomical on the left only. All that portion of the 
heart lying beneath the sternum and behind the left third 
rib and second intercostal space cannot be brought out. 

2. The boundary of the cardiac dullness above and to 
the left is parallel to that of the cardiac flatness, and is 
removed two to three centimeters from the same. 

Mobility of the Relative Heart's Dulhiess. 

The above boundaries suffer displacement just as do 
those of the absolute flatness on deep inspiration and 
changes of position ; and this is about the same in kiiid 
and extent as in the absolute flatness. They maintain 
the same relation to each other, therefore, as in quiet 
respiration or the dorsal decubitus. Two points deserve 
to be mentioned, however. 



36 PERCUSSION OUTLINES. 

First, In those cases where the absolute flatness quite 
disappears on deep inspiration, there still remains on 
the left edge of the sternum, from the level of the fourth 
to the sixth rib, a region of relatively dull sound several 
centimeters broad. 

Second, When absolute flatness appears on the right 
of the sternum in the right lateral decubitus, a zone of 
dull resonance one or two centimeters in width may also 
be found surrounding this flatness. (Weil.) 

PATHOLOGY. 

Diminution or disappearance of flatness in the cardiac 
area is observed : 1. In congenital dexiocardia ; 2. In 
left-sided pneumothorax with great expansion of the chest 
and displacement of the neighboring organs; 3. In ex- 
tensive emphysema ; 4. In pneumo-pericardium. 

In congenital dexiocardia, usually also in pneumo- 
thorax of the left side, a cardiac flatness may be demon- 
strated on the right side between the right edge of the 
sternum and the right parasternal or mammillary line 
between the third or fourth and the sixth rib ; while in 
great emphysema and pneumo-pericardium there is en- 
tire absence of all cardiac flatness. In the extremest 
degrees of emphysema there is everywhere above the 
lower border of the lungs, even on the left side, a loud, 
clear pulmonic sound. In less pronounced cases absolute 
flatness may be absent, but a narrow zone of relative 
dullness may be demonstrated along the left edge of the 
sternum in the fifth and sixth intercostal space. In the 
slightest degrees of emphysema, both relative and abso- 
lute cardiac flatness can still be outlined, though they are 
smaller and are situated lower down than in normal 
conditions. 

The diminution of the cardiac area of flatness in em- 
physema is explained by the expansion of the lung into 



HEART. 37 

the sinus mediastino-costalis. A disappearance of the 
absolute cardiac flatness may occasionally be caused by 
the transmission of resonance from the neighboring lung, 
when the intercostal spaces are very narrow, and the cos- 
tal cartilages are very elastic. 

In the rare cases where free gas is present in the peri- 
cardial sac, a clear tympanitic, almost metallic, sound is 
obtained over the heart when the patient is lying on the 
back. When the patient sits up or bends forward the 
sound over the lower portion of the above tympanitic 
region is dulled because the heart and any fluid pres- 
ent in the pericardium sinks forward and downward. 

Increase of the Cardiac Flatness. 

In by far the greater number of cases, this is due to 
hypertrophy and dilatation of the whole heart, or portions 
of the same, or to the presence of fluid in the pericardium. 
Again, when the heart is of normal size, and the pericar- 
dium does not contain fluid, the cardiac dullness may 
appear to be enlarged upward to the left, or toward the 
right, or in fact in all directions, by reason of solidifica- 
tion or retraction of the pulmonary borders. It is not 
possible to distinguish by means of percussion alone which 
part of the dullness belongs to the heart, and which to the 
unaerated lung (or fluid collected in the sinus mediastino- 
costalis). 

The form of cardiac dullness varies according as the 
left or right ventricle is especially implicated in the dila- 
tation and hypertrophy. 

In hypertrophy of the left ventricle the boundaries of 
both the absolute flatness and relative dullness are moved 
chiefly to the left and downward, more rarely upward, 
while the right border remains at the left edge of the 
sternum or near it. With a moderate increase of volume, 
as from arterio-sclerosis, the absolute flatness may begin 



38 PERCUSSION OUTLINES. 

at the third rib, and extend three or four centimeters 
beyond the mammillary line at the fifth rib. While, for 
example, in insufficience of the aortal valves and conse- 
quent high degree of hypertrophy and dilatation of the 
left ventricle, the upper boundary may be normal, and 
the left may reach into the anterior axillary line. 

In dilatation and hypertrophy affecting chiefly the right 
side of the heart, the upper borders of both absolute 
flatness and relative dullness are normal, the left border 
extends but slightly outward, and the right border either 
remains at the left edge of the sternum, or, where the di- 
latation is excessive, a new area of dullness on the right 
is met with, divided from the normal area by the resonant 
sternum. This may begin as high as the fourth costal 
cartilage on the right edge of the sternum, and at the 
level of the fifth and sixth costal cartilages extend one 
and a half to two centimeters bej^ond it. 

The displacements caused by respiratory movements 
and changes of position with hypertrophy are more con- 
siderable than in the normal condition. During a deep 
inspiration the absolute cardiac flatness suffers a consider- 
able decrease in extent toward the left, and in decubitus 
on the right side, not only does the same phenomenon 
occur, but in addition there is found absolute flatness on 
the right of the sternum. Change from the prone to 
the upright position of the body does not alter the boun- 
daries. 

With pleuritic effusion on the left side the heart is dis- 
placed to the right, and with excessive accumulation of 
fluid may be carried as far as the right axillary line. 

With effusion on the right side the heart is carried to 
the left, and may reach to the left axillary line. 

With excessive distention of the abdomen, either by 
ascites, tumors, or tympanites, the heart is pushed up- 
ward. In a case of great ascites, confining the patient 



PERICARDIUM. 39 

upon the left side, we found the cardiac impulse at the 
third intercostal space in the left axillary line. The im- 
pulse presented a peculiar intermittency, coinciding with 
the respiratory movements, and was very strong during 
expiration, while it disappeared with full inspiration. 

The mobility of the cardiac boundaries may be lim- 
ited by pericardial and pleural (sinus mediastino-costalis) 
adhesions. 

PERICARDIUM. 

Anatomy. — The external or parietal layer of the peri- 
cardium is the only one presenting any interest to us. 
It corresponds neither in form nor volume with the inner 
la er covering the heart, but is so much broader than 
the latter, that even when the heart is moderately filled 
with blood, it will still hold six ounces of water without 
being extremely distended. (LusCHKA.) The physio- 
logical purpose of this arrangement is evident, and in 
pathological conditions it affords room for the dilatation 
and hypertrophy of the heart which are compensatory to 
valvular lesions, emphysema, and so forth. The peri- 
cardium reaches beyond the base of the heart up to the 
middle of the first costal cartilage on the right side, and 
on the left to the middle of the second costal cartilage. 
It extends below on the right to the mam miliary line in 
the fifth intercostal space, and on the left to the sixth 
rib at least in the mammillary line. It is capable of some 
distention beyond these points. 

PATHOLOGY. 

Fluid in the pericardium collects in the lowermost part 
first; and Rotch, basing his conclusions on a series of 
injections, claims that flatness in the fifth right inter- 
costal space, three centimeters from the edge of the 
sternum, is diagnostic of this condition. The figure ob- 
tained by percussion is triangular, with a broad base 
below and a blunt apex above. 



40 PERCUSSION OUTLINES. 

With moderate collections of fluid, the blunt apex of 
the triangle is found in the third or second intercostal 
space, near the left edge of the sternum. It runs from 
here obliquely downward, and to the right as far as the 
sixth rib in the sternal or parasternal line, and to the left 
beyond the mammillary line. 

If the fluid is very abundant, the apex may be situated 
at the manubrium sterni, while the base reaches from the 
right mammillary line at the level of the sixth intercos- 
tal space, to the left axillary line at the height of the 
seventh rib or even seventh intercostal space. The area 
of absolute flatness is said to be greater in the erect than 
in the prone position, and if this be true it forms a most 
important point in the differentiation of pericardial ef- 
fusion from enlarged heart. 



CHAPTER V. 

LIVEB. 

Anatomy. — Three quarters of the liver lie in the right 
half of the upper abdomen. This includes the lobus 
dexter, lobus Spigelii, and generally the entire lobus 
quadratus. The boundary between the right and left 
lobes lies, in many cases, in the median line, but it may 
be a finger-breadth to the right of the same. The left 
lobe pushes in between the stomach and that portion of 
the diaphragm upon which rests the heart. It extends 
five to six centimeters to the left of the median line. 

The upper border of the liver is a curved line corre- 
sponding to the arch of the diaphragm. Its highest point 
is in the right mammillary line, where it stands on a 
level with the fifth pair of ribs in front, and with the 
ninth dorsal vertebra behind. At the end of expiration 
it is five centimeters higher than the pneumono-hepatic 
border. 

The lower edge of the liver begins at the eleventh rib 
in the vertebral line. It runs along this rib to the scap- 
ular line, when it turns obliquely upward and forward, 
and emerges from beneath the costal arch in the mam- 
millary line, at the level of the tenth costal cartilage. 
It then crosses the epigastrium, meeting the median line 
of the body between the upper and middle thirds of the 
distance from the umbilicus to the apex of the xiphoid 
cartilage. It disappears behind the left costal arch be- 
tween the left mammillary and parasternal lines. 



42 PERCUSSION OUTLINES. 



PERCUSSION. 

The liver presents two percussion areas and three 
borders for consideration — the first area is the portion 
covered by lung; and it gives a dull resonance on strong 
percussion. The second area is the lower part of the 
liver, which is not covered by lung, but lies in actual 
contact with the chest wall. Here we obtain a flat sound 
on percussion. 

The superior border corresponds to the arch of the dia- 
phragm, as previously remarked. Near the vertebral 
column it is impossible to outline this border, owing to 
the resonance of the intervening lung. On the sides and 
in front it can usually be made out with sufficient ac- 
curacy for practical purposes. (Plate IV., P Q.) With 
a very thick lung, however, or with emphysema, it is im- 
possible to detect it. That portion of the superior bor- 
der which underlies the heart cannot be distinguished 
because there is no difference between hepatic and car- 
diac flatness. 

The inferior border is more accessible, and can gene- 
rally be made out by light percussion. It is indicated 
by the transition from hepatic flatness to intestinal and 
gastric resonance. When the intestines and stomach 
are very resonant the percussion must be very light. 

The pneumono '-hepatic border separates the hepatic 
flatness from the pulmonic resonance, and has already 
been described. Irrespective of the actual size of the 
liver, the area of hepatic flatness will depend upon the 
position of this border, and therefore will diminish with 
inspiration and emphysema, and be increased by expira- 
tion or other shrinkage of the lung. 

Gall Bladder. — The gall bladder ordinarily lies 
beneath the liver, and is inaccessible to palpation or per- 
cussion. Let the exit of bile be obstructed, however, 



LIVER. 43 

and the gall bladder becomes distended by accumulated 
secretion, and it will produce a well-defined tumor. In 
such cases the tumor appears at the angle formed by the 
junction between the lower border of the liver, as it 
emerges from the costal arch, and the outer border of the 
rectus abdominis muscle. The dull area is then usually 
pear-shaped, and may be defined by the resonant intes- 
tines about it. 

PATHOLOGY. 

Changes in the size of the liver are often very difficult 
to determine by percussion, and even when variations in 
the extent of hepatic flatness are detected it is still diffi- 
cult to decide whether such variations are due to modifi- 
cations of the liver itself or of the neighboring organs. 
A diminution of the area of hepatic flatness may be pro- 
duced by acute or chronic atrophy of the liver. It may 
also be due to the intrusion of coils of intestine between 
the liver and abdominal wall. T} T mpanites, ascites, ova- 
rian and uterine tumors will produce the same result by 
pushing the liver further up behind the lung. Emphy- 
sematous enlargement of the lung, by lowering the pneu- 
mono-hepatic border, will make the liver appear small. 
An actual diminution of the liver can be diagnosed only 
when, with decreased flat area, we still find the pneumono- 
hepatic border at normal height, and we can exclude all 
conditions which produce elevation or twisting of the 
organ. The most difficult cases to decide are those where 
a loop of intestine lies between the liver and the chest 
wall. Frerichs says that this condition may be surmised 
when one of the diameters of the liver is unusually small 
as compared with the remaining diameters. 

An enlargement of the area of hepatic flatness occurs 
with hypertrophy of the organ itself ; also with any re- 
traction of the lung which elevates the pneumono-hepatic 
border. Displacements of the liver by pressure of tho- 



44 PERCUSSION OUTLINES. 

racic tumors or pleuritic exudations cause an enlargement 
of the flat area. In all such cases, therefore, it is ob- 
vious that no diagnosis regarding the actual size of the 
liver can be made until all associated conditions have been 
carefully reviewed. 

Weil gives the following valuable schedule of possible 
complications, which cannot fail to be of service in de- 
ciding many obscure cases. 

1. The inferior border of the liver is in normal posi- 
tion : — 

(a) The pneumono-hepatic border is high : en- 
largement of liver upward ; medium-sized pleu- 
ritic effusion ; enlargement of liver with coin- 
cident dislocation upward, as in hypersemia or 
amyloid liver with ascites. 

(6) The pneumono-hepatic border is low : emphy- 
sema of moderate degree. In such a case the 
height of the hepatic dull zone, above the 
pneumono-hepatic line, is normal or increased. 

2. The inferior border of the liver is too low. 

(a) The pneumono-hepatic border is high : very 
large hypertrophy or tumor of liver : large pleu- 
ritic exudation. 

(5) The pneumono-hepatic border is normal : hy- 
pertrophy of liver ; anomalous position of the 
same. 

(<?) The pneumono-hepatic border is low : exces- 
sive emphysema ; pneumothorax. 

3. The inferior border of the liver is too high. 

(a) The pneumono-hepatic border is high : dislo- 
cation upward. 

(5) The pneumono-hepatic border is normal : atro- 
phy of liver ; dislocation upward. 



LIVER 45 

4. The hepatic flatness is entirely absent. 

Oblique position of the liver, with meteorismus and 
ascites ; intervention of intestines ; formation 
of free gas in the peritoneal cavity. 

5. Transposition of the hepatic flatness to the opposite 
side of the body in cases of congenital transposition of all 
the internal viscera. 



CHAPTER VI. 

THE SPLEEN. 

Anatomy. — The spleen is situated in the left hypo- 
chondrium, between the diaphragm, the left kidney, and 
the posterior wall of the stomach. It extends from the 
ninth to the eleventh rib, with its longest diameter di- 
rected obliquely forward and downward, following the 
course of these ribs. We distinguish an upper end 
(Plate II.) distant two centimeters at least from the 
body of the tenth dorsal vertebra, and an anterior end, 
corresponding to the point lying nearest the middle line 
of the body. When the spleen is oval in shape, besides 
the upper and anterior ends, we may speak of two bor- 
ders, an anterior and a posterior, which unite at G and 
H. The anterior end is about in the axillary line, and 
does not extend beyond the linea costo-articularis under 
normal conditions. The anterior edge corresponds to the 
course of the ninth rib ; in its upper portion it is covered 
by lung, and only emerges from the pulmonary edge in 
the posterior axillary line. In the angle made by the 
lower border of the lung and the spleen, the stomach and 
colon are located. The posterior edge follows the elev- 
enth rib, and overlaps the left kidney a short distance 
in its middle third. Where the posterior edge of the 
spleen and the outer border of the kidney meet, the de- 
scending colon is situated. When the shape of the spleen 
is more rhomboidal, its front edge follows the course of 
the ninth rib still farther forward than in the oval form, 



SPLEEN. 47 

and the lower edge runs obliquely backward and down- 
ward. 

Notice : 1. About a third of the spleen (the upper 
end, a part of the front and posterior borders) is covered 
by lung. 

2. The posterior border of the spleen lies in apposition 
to the anterior border of the left kidney for about a third 
of its course. 

PERCUSSION. 

We are unable to define by percussion that portion of 
the spleen which is covered by lung. We can at most 
obtain, in some cases, by strong percussion, a relatively 
dull sound above the lower edge of the lung, extending 
from the anterior axillary line to midway between the 
posterior axillary and scapular lines, or to the scapular 
line. The upper border of this area is parallel to the 
pneumono-splenic border at a distance of two or three 
centimeters. Between the scapular line and the vertebrse 
relative dullness for the spleen is no more demonstrable 
than is the case with the liver on the other side. Be- 
tween the anterior axillary line and the mammillary line, 
as a rule, there is also no relative dullness above the edge 
of the left lung. On gentle percussion the sound here is 
as loud as it is higher up, and on stronger percussion it 
usually becomes tympanitic, because the stomach, which 
is full of air, is set in vibration underneath the lung. 
The same condition frequently occurs also between the 
posterior axillary and scapular lines, so that here like- 
wise there is no relative dullness above the pneumono- 
splenic boundary. 



48 PERCUSSION OUTLINES. 

DETERMINATION OF THE BOUNDARIES OF THE 
SPLEEN. 

The best position for the patient to assume is decubi- 
tus on the right side, diagonal decubitus (on the right 
shoulder-blade and right hip), or standing erect. The 
disadvantage of the first position is that the lower end 
of the organ is often difficult to define, from the near 
approach of the crest of the ileum to the lower ribs. 
The disadvantage of the second position is that unless 
the patient is near the edge of the bed, it is often im- 
possible to define the posterior boundary. While the 
chief disadvantage of the last position is the impossi- 
bility at times of placing the patient erect. Where 
great accuracy is sought, it is well to compare the bound- 
aries found in the recumbent position with those obtained 
while the patient is upright. If the spleen is percussed 
in the upright position, we must in the first place deter- 
mine the pneumono-splenic border, by percussing verti- 
cally downward from above, in the vertebral, scapular, 
posterior, middle, and anterior axillary lines. We thus 
obtain the border B D (Plate V.), corresponding to the 
lower edge of the left lung. Below the edge of the lung 
we find, as far as the point E in the posterior (or middle) 
axillary line, a dull sound ; further forward, a tympanitic 
sound. If we percuss vertically downward in the axillary 
region, we find, at I and K, the transition of the dull to 
the loud tympanitic sound, and thus obtain the oval fig- 
ure of dullness E K L. Posteriorly, the splenic dullness 
becomes merged in that of the kidney and thick dorsal 
muscles, and is difficult to outline. 

The size of the organ is determined by the vertical 
diameter of dullness in the axillary line, and by the dis- 
tance of the anterior end of dullness from the costal arch. 
To give the normal boundaries of splenic dullness in the 



SPLEEN. 49 

upright position more exactly, the pneumono-splenic 
angle, as a rule, is in the posterior axillary line ; or be- 
tween it and the middle axillary line, at the level of the 
ninth rib ; more rarely of the ninth or eighth intercostal 
space. The distance of the lower splenic border from the 
npper one in the vertical line is five and a half to six and 
a half, sometimes even seven, centimeters. The anterior 
end of the spleen is behind the costo-articular line, or 
at most, just reaches it ; or in other words is four to six 
centimeters from the costal arch. In using the linea 
costo-articularis as a defining point for the position of the 
anterior border of the spleen, we must remember that, on 
account of the varying length of the eleventh rib in dif- 
ferent people, this line may be carried more toward the 
front, sometimes more towards the back. 

To define the splenic dullness we must employ some- 
times gentle, sometimes strong percussion. Thus, while 
the. pneumono-splenic boundary between the axillary and 
scapular lines, as a rule, is better obtained by medium 
strong percussion, the definition from the tympanitic 
sound of the stomach and colon, in cases where these or- 
gans contain much gas, is better made by gentle percus- 
sion, since by strong percussion the organs lying behind 
the spleen are set in vibration, and their tympanitic 
sound either causes the splenic dullness to appear too 
small, or to disappear altogether. On the other hand, 
the difference in sound is more distinct on strong per- 
cussion when the stomach and colon have fluid or solid 
contents. The sound is seldom perfectly flat in the re- 
gion where the spleen is accessible to percussion. There 
is usually a tympanitic accessory sound which is espe- 
cially distinct toward the edges of the organ. The boun- 
daries of the spleen, therefore, as of the liver, are to be 
placed where the tympanitic sound becomes clear and 
loud ; or better, where the loud tympanitic sound of the 



50 PERCUSSION OUTLINES. 

stomach and colon begins to be dulled, as we approach the 
splenic region. 

On change from the upright to the right lateral decu- 
bitus, the pneumono-splenic border sinks two to four cen- 
timeters, and the anterior extremity of the spleen ad- 
vances to or beyond the linea costo-articularis. The dull 
area of the spleen thus assumes a narrower and more 
horizontal position. 

Slight deviations from the conditions already given are 
exceedingly common ; as, for instance, instead of the oval 
figure described above as normal, we may obtain by our 
percussion a figure distinctly triangular or rhomboidal ; 
or, especially when the patient is in the upright posture, 
the longest diameter may run more vertically. Still 
these are all rather exceptions to the rule. Other varia- 
tions from the conditions mentioned are caused by differ- 
ences of age in the individual. Corresponding to the 
lower position of the pneumono-splenic border, we always 
find in advanced age the upper border of the splenic dull- 
ness deeper, and the splenic dullness itself smaller than 
in persons of middle age. It is of the greatest practical 
importance to know all the conditions which render de- 
termination of the splenic boundaries either difficult or 
impossible. Cases are by no means rare in which, while 
the lower border of the left lung has a normal position, 
yet the splenic dullness cannot be demonstrated at all, 
or it has a very circumscribed area. In such cases the 
pulmonic sound suddenly changes to a loud tympanitic 
one. The conditions which cause a diminution or disap- 
pearance of the splenic dullness in perfectly healthy indi- 
viduals are usually merely transitory, and depend on the 
presence of a considerable volume of gas in the organs sur- 
rounding the anterior and posterior edges of the spleen, 
that is, in the stomach and colon. They are of less prac- 
tical importance than a diffused dullness so frequently 



SPLEEN. 51 

seen in health, extending far beyond the normal bounda- 
ries, and they do not lead so often to a false diagnosis. 
This diffused dullness in the region of the spleen is 
readily explained. If the underlying colon and stomach 
do not contain gas, but are filled with solid or liquid 
substances, they give forth a sound which is indistin- 
guishable from that of the spleen. The splenic dullness 
then runs over into that of these organs, and therefore 
appears enlarged. In such cases, an examination after 
fasting for a time, or after a brisk cathartic, will show 
that the splenic dullness may be normal after all. Again, 
a very fat omentum may stretch to the left end of the 
transverse colon, and displace it from the thoracic wall. 
The shape of the dullness will often rouse suspicion that 
we have something else before us ; as, for example, when 
the dullness is only five or six centimeters broad and 
reaches to the costal arch, or when it has a breadth of 
eleven centimeters and does not extend beyond the linea 
costo-articularis. In cases where the shape of the dull- 
ness is correct for that of the spleen, but differs only 
in point of size, we may often arrive at the truth by 
comparative percussion in different positions. The true 
splenic tumor gives approximately the same relation to 
the linea costo-articularis on repeated percussion, while 
the boundaries of the apparent tumor are characterized 
by their changeableness. 

Passive Mobility. — The displacements to which the 
splenic dullness is subject on change of position have 
been already mentioned. There still remain the respira- 
tory displacements, which are worthy of brief notice. 
They have been hinted at above in speaking of the po- 
sition of the diaphragm. With every inspiration the 
splenic dullness is diminished in size and brought lower, 
while the anterior end of the organ sometimes remains 
undisturbed in its place and sometimes moves forward 



52 PERCUSSION OUTLINES. 

and downward one or two centimeters. The descent of 
the lower border depends on the descent of the whole 
organ through contraction of the diaphragm ; the lower 
border, after the deepest possible inspiration, is about one 
centimeter lower, and the pneumono-splenic border about 
three to four centimeters lower than before. If a deep 
inspiration is made while in the right lateral decubitus, 
the splenic dullness disappears completely, except in a 
narrow line. In deep expiration the splenic dullness as- 
cends and enlarges, because the lower border makes a 
smaller excursion than the upper border. 

PATHOLOGY. 

The spleen may be either diminished or increased in 
size, or it may be dislocated. 

In mentioning the difficulties attending the determina- 
tion of the splenic boundary, we called attention to the 
fact that sometimes the splenic dullness was wholly ab- 
sent. In certain diseases, emphysema, gas or fluid in the 
peritoneal sac, we find it either much diminished or ab- 
sent, for reasons sufficiently obvious. In wandering spleen 
absence of dullness in the normal area may assume diag- 
nostic importance, especially when a tumor situated else- 
where in the abdomen can be replaced, and supply the 
absent dullness. 

Splenic Tumor. — The cautions mentioned above will 
fully illustrate the care necessary in determining the ex- 
istence of splenic enlargement. A diagnosis of such en- 
largement, therefore, should not be made from one ex- 
amination. Moderate enlargements of the organ are 
shown by increase of the vertical diameter of the dull- 
ness from five or six to nine or twelve centimeters; also 
by the advance of the anterior end to, or beyond, the 
costal arch. At the same time the pneumono-splenic 
border moves upward. The increase in the breadth of 



SPLEEN. 53 

the dullness is caused by the descent of the lower and the 
ascent of the upper border of the spleen. The lower 
border may then reach in the right lateral decubitus as 
far as the twelfth rib or even lower, the pneumono-splenic 
border may stand in the middle axillary line at the 
eighth rib, seventh intercostal space, or at the seventh 
rib even. 

The intensity of dullness in enlarged spleen is almost 
without exception greater than that in the normal 
spleen. 

The dislocation resulting from fluid in the chest is for- 
ward and downward, or the spleen may be made to as- 
sume a more vertical position, and at the same time be 
depressed. 



CHAPTER VII. 

THE STOMACH. 

Anatomy, — The stomach is so placed in the abdomen 
that, no matter what changes of volume it undergoes, 
about three quarters of it lie in the left hypochondrium 
and one quarter in the epigastrium. Its longest diameter 
runs obliquely from behind downward and forward to- 
ward the right side ; the pyloric end curves slightly up- 
ward, as a rule, in the median line, so that, on moderate 
distention of the stomach the lowest point of the organ 
falls in the middle of the space between the end of the 
processus xiphoideus and the umbilicus. A horizontal 
line from this point to the left border of the ribs runs 
just below the junction of the greater curvature with the 
costal arch. 

The beginning of the stomach, the cardiac portion 
(Plate I.), or, more correctly, the abdominal portion of 
the oesophagus, is about on the level of the sternal edge 
of the left sixth intercostal space, distant at least ten 
centimeters from the anterior wall of the thorax. 

The pyloric portion lies in the right half of the epigas- 
trium, and, as a rule, barely reaches to the right costal 
arch. 

The small curvature hugs the lumbar vertebrae. 

The great curvature is turned toward the lateral wall 
of the left hypochondrium and the inner side of the an 
terior abdominal wall. 

The front, upper side, of the stomach, while in the left 



STOMACH. 55 

hypochondrium, follows the concavity of the diaphragm, 
the fundus occupying the highest point of the latter 
(level of the fifth rib). This surface of the stomach is, 
to a great extent, overlaid by the base of the left lung ; 
while the portion located in the epigastrium is in part 
separated from the anterior abdominal wall by the left 
lobe of the liver. 

The lower posterior surface of the stomach, which is in 
part directed toward the dorsal wall of the abdomen, and 
in part directed downward, at no place comes in direct 
contact with the abdominal wall. Along the greater curv- 
ature runs the transverse colon, ending in the region of 
t*he fundus as the flexura coli sinistra. 

Notice : 1. The whole posterior and lower side of the 
stomach nowhere lies next the wall of the body. 

2. The cardia, small curvature, a part of the front up- 
per surface, are separated from the anterior abdominal 
wall by the left lobe of the liver ; another part of the 
front upper side and the great curvature are separated 
from the wall of the thorax by lung. 

3. Only a small portion of the anterior superior sur- 
face lies directly against the abdominal wall. (Plate 
L, w.) 

PERCUSSION. 

Percussion of the stomach presents certain difficulties 
due to its varying size, according to the degree of dis- 
tention with fluid, solid, and gas, and to the tension of the 
abdominal wall. The sound given forth is, according to 
these different conditions, dull, tympanitic, or metallic. 
In addition, there is also the sound of the colon, which we 
must distinguish from that of the stomach, and which, 
with the changeable degree of distention, is often diffi- 
cult. 

In percussing the stomach, we assume the organ to be 
partly filled. In the dorsal decubitus the solid and fluid 



56 PERCUSSION OUTLINES. 

contents collect in the posterior portion of the stomach. 
While the gaseous contents rise anteriorly, and with a 
moderate degree of distention of the gastric wall, occa- 
sion a tympanitic sound. The boundaries of this sound 
are as follows, under the conditions given above. 

1. Above and to the right the gastro-hepatic boundary. 
(Plate I.) 

2. Above and to the left the pneumono-gastric bound- 
ary. 

3. Below the lower boundary of the stomach, corre- 
sponding to the greater curvature. 

4. Between the gastro-hepatic and pneumono-gastric 
boundaries, in cases where the left lobe of the liver is 
overlaid toward the left by the absolute cardiac flatness, 
is a gastro-cardiac boundary. 

Of these boundaries the only actual one is the lower. 
This is determined by a change from the tympanitic 
sound of the stomach to one of a different pitch or clear- 
ness, coming from the transverse colon ; and it is situated 
midway between the end of the processus xiphoideus and 
the umbilicus, and runs thence in a tolerably horizontal 
line to the left hypochondrium, and crosses the costal 
arch about on a level with the ninth costal cartilage ; 
thence following very nearly the course of the eighth rib, 
it disappears behind the lower edge of the lung in the 
middle axillary line. The lower border of the stomach 
can be followed but a few centimeters to the right of the 
median line, because it passes behind the lower edge of 
the liver. The lower border varies from the above points 
according to the greater or less degree of distention of 
the stomach. The middle and right hand portions of 
this boundary vary but little from the points given ; the 
left, on the other hand, is capable of considerable varia- 
tion. The less the degree of distention of the organ, the 
more does it retract from the pneumono-splenic angle, till 



STOMACH. 57 

it may meet the lung at the sixth rib even. In great 
distention of the stomach, on the other hand, this entire 
angle may be filled out. From the above facts, it is plain 
that we must be content with defining that portion of the 
stomach lying next the anterior thoracic and abdominal 
wall. 

PATHOLOGY. 

Diminution of the gastric area of resonance may occur 
from enlargement of the left lobe of the liver, from sple- 
nic tumor, from an enlarged heart, or from emphysema of 
the lung; the stomach in each instance remaining of 
normal size, but being overlaid by the pathological 
organs. 

Increase of the gastric area of resonance, gastric dila- 
tation is of greater importance. When the patient is 
examined while lying on the back, the lower border cor- 
responding to the greater curvature, is found to be lower 
than normal, either at the umbilicus, below it, or, in ex- 
treme cases, near the symphysis pubis. When the patient 
is examined in the erect position, a dullness is obtained, 
the lower border of which is somewhat lower than that 
of the tympanitic resonance found in the horizontal po- 
sition, and is due to the gravitation of the contents of 
the stomach. 



CHAPTER VIII. 

THE KIDNEYS. 

Anatomy, — The kidneys lie on each side of the verte- 
Dral column, close to the posterior abdominal wall, at the 
level of the last dorsal and two or three upper lumbar 
vertebrse. The right kidney is usually a little lower than 
the left (Plate HI.) The concave edge is toward the 
spine, the convex edge is directed outward. The upper 
end of the right kidney extends under the liver, so that 
about a third of it is covered by the latter. The left 
kidney touches the posterior lower border of the spleen, 
as described above. Viewed from behind, the kidneys 
are overlaid and about half covered by the eleventh and 
twelfth ribs. The duodenum and ascending colon are in 
front of the right kidney, and the descending colon is 
in front of the left kidney. The colon encircles the 
outer edge of each kidney. Behind, the kidneys lie on 
a thick layer of muscle, the pillars of the diaphragm, 
quadratus lumborum, transversus abdominis, sacro-spina- 
lis, and latissimus dorsi. The lower end of the kidneys 
is two to six centimeters above the crest of the ileum. 
The outer edge extends ten centimeters from the median 
line, so that the two outer edges are twenty centimeters 
apart. 

PERCUSSION. 

In the normal condition, the kidneys are not acces- 
sible to percussion, owing to the thickness of the muscles 
of the back, and to the resonance of the neighboring 



THE KIDNEYS. 59 

intestines. The dullness obtained in the renal region, 
and usually attributed to the kidneys (Plate VIL, H I 
and K l), has been found by Weil to be the same after 
extirpation of one kidney ; and in a case of floating kid- 
ney this dullness was the same both before and after 
reposition of the organ. 

Extreme cases of hydronephrosis and very large tumors 
of the kidneys may produce a distinct flat area of their 
own. 



CHAPTER IX. 

THE BLADDER. 

Anatomy, — The bladder is situated in the pelvis, be- 
hind the pubes. In the male, the rectum is directly 
behind it ; and in the female, the uterus and vagina. 
The shape and position of the bladder are greatly in- 
fluenced by age, sex, and the degree of distention of the 
organ. In infancy, the bladder is conical and projects 
into the abdomen above the pubes. In the adult, when 
empty, it is a triangular sac (three centimeters in diam- 
eter usually) flattened from before backward, with its 
apex reaching nearly as high as the upper border of the 
symphysis pubis. When slightly distended, it has a 
rounded form ; when greatly distended, it is oval. Its 
longest diameter in the latter condition is vertical and 
curved slightly forward. In the female, the bladder is 
larger in the transverse than in the vertical diameter, and 
is said to be more capacious than in the male. When 
contracted, it has two lateral sinuses, which override 
the vagina like saddle-bags. This fact, together with the 
greater roominess of the female pelvis, permits a consid- 
erable accumulation of urine in the bladder without any 
appearance of the organ above the pubes. 

The average capacity of the bladder, in health, is 500 
cubic centimeters. 

PERCUSSION. 

The empty bladder in the adult cannot be reached by 
percussion. How large a quantity of urine is requisite to 



THE BLADDER. 61 

render the bladder accessible depends on the curve and 
and thickness of the abdominal wall, and on the condition 
of the neighboring intestine. The first effect of the col- 
lection of urine within the bladder is to render the organ 
spherical; and it is not till a considerable quantity is 
present, even in the most favorable subjects, that any- 
thing like certainty can be attained on percussion. We 
have found that an area of flatness extending ten centi- 
meters above the pubes and nine centimeters in breadth, 
coincided with six hundred and seventy cubic centimeters 
of urine drawn immediately after the measurements were 
made, in a man with emaciated and relaxed abdominal 
wall. In another man, with a moderately prominent ab- 
domen, four hundred cubic centimeters did not give any 
evidence of its presence. 



CHAPTER X. 



THE UTERUS. 



In the unimpregnated condition, the uterus lies below 
the brim of the pelvis. During pregnancy, after the 
fourth month it begins to rise above the brim, and may 
be outlined under favorable conditions. At the fifth 
month, it stands half way between the symphysis pubis 
and the umbilicus, in the median line. At the sixth 
month it has reached the umbilicus. At the seventh 
month it extends one third the distance between the 
umbilicus and the processus xiphoideus. At the eighth 
month, it is two thirds the distance between the above 
points ; and at the ninth, it touches the lower end of the 
processus xiphoideus. 



Fig. 4. (Chadwick.) 



LUNAR 
MONTHS. 

9th. 




THE UTERUS. 63 

The resonance of the surrounding intestines often ob- 
scures the percussion outlines of the impregnated uterus, 
and more information can usually be obtained by palpation 
than by percussion. 



CHAPTER XI. 

THE PERITONEUM. 

Ascites. — The amount of fluid within the peritoneum 
must be considerable to give evidence of its presence by 
percussion. If it lies next the abdominal wall we obtain 
dullness or flatness, according to its quantity. Free fluid 
gravitates to the lowest part of the sac, so that the 
boundaries of dullness or flatness vary with the position 
of the patient. With moderate effusions, the lower bor- 
der of the lungs, heart, and liver stand higher than normal. 
The hepatic flatness appears to be decreased in size, be- 
cause the intestines are displaced upward, and, where the 
collection of fluid is large, the liver is tilted on its axis. The 
splenic dullness is also found to be higher than normal and 
smaller, unless the ascites depends on a condition which 
gives rise to splenic tumor. When the patient is in the 
supine position the upper border of flatness is crescent- 
shaped, with the concavity directed upward. In the erect 
posture it is horizontal. In the lateral decubitus the 
flatness changes to the lower side, and is replaced in the 
opposite flank by the clear resonance of the intestines. 
When the amount of fluid is very great a flat sound is 
obtained everywhere, except in the epigastrium, near the 
processus xiphoideus, where it remains somewhat tym- 
panitic. 

The points of differentiation from Ovarian Tumor are 
as follows : — 

In Ascites, in the dorsal decubitus, the sound is tym- 



THE PERITONEUM. 65 

panitic, in a curved line with the concavity upward, the 
epigastrium being resonant and the flanks flat. Fur- 
thermore, change of position gives modification of the 
curve. * 

In Ovarian Tumor, the tympanitic resonance remains 
longest in the flanks ; while, as a rule, the highest point 
of flatness is in the middle line of the body, and change 
of position, unless the tumor be small, gives rise to less 
modification of the flatness. (Olshausen.) 

The above distinctions are not absolute, since strong 
percussion may bring out a deep-seated resonance in colon 
or ccecum, or deep pressure may displace ascitic fluid. 

In a patient with considerable ascites, we found that 
in the dorsal decubitus, the line of flatness commenced at 
the costal arch in the parasternal line on each side, and 
swept round in a gentle curve to two and a half centime- 
ters below the umbilicus. 

GAS IN THE PERITONEUM. 

If there is free gas in the peritoneum the sound has the 
same pitch and distinctness throughout the whole abdo- 
men ; this is, according to the degree of distention of the 
abdomen, tympanitic, or metallic. 

The hepatic flatness and splenic dullness may be absent 
when the amount of gas is large, and there are no adhe- 
sions of these organs to the abdominal wall. 

In Meteorism similar results to the above may be ob- 
tained by percussion, but usually the different clearness 
and pitch of the sound in various parts of the abdomen 
indicate that the gas is contained in coils of intestine of 
different size, and not in a single cavity. More impor- 
tant data for distinguishing between these two condi- 
tions, however, are obtained by other methods of inves- 
tigation. 

5 



Plate I. 




Anatomical Borders — Anterior View. (Weil.) 



A B, border of the right pleural sac. 

C 0, border of the left pleural sac. 

E F, edge of the right lung. 

6 H, edge of the left lung. 

I , upper incisura interlobular is of the right lung. 

K, lower incisura interlobularis of the right lung. 

L, left incisura interlobularis. 

M N, right border of the heart. 

N O, lower border of the heart. 

P O. left border of the heart. 



Q, sinus -mediae tinocos tails, situated between the edge 
of the pleura and incisura cardiaca of the anterior 
border of the left lung. 

R, highest point of the portion of liver covered by lung 

S, lower edge of the liver. 

T, cardiac portion of the stomach. 

U, pyJoric portion of the stomach. 

V, small curvature of the stomach. 

W, greater curvature of the stomach. 



Plate II. 










Anatomical Borders on Left Side. (Weil.) 



A B, lower border of the left lung. 
A C, lower boundary of the pleura. 
D E, incisura Interlobularis. 
F, edge of the left lobe of the liver. 



H G, anterior and posterior ends of the spleen. 

K, kidney. 

N, stomach in moderate distention. 



Plate III. 



i Mi 




Anatomical Borders — Posterior View. (Weil.) 

A, B, lower borders of the lungs. H, spleen. 

C, 0, lower borders of the pleuree. I, lower border of the liver. 

E, F, incisurse inter lobular es. K, L, kidneys. 

G, point where the right incisure, divides into the sulc. interlob. dext. super, and infer. 



Plate IV. 




Percussion Borders in Middle Age. (Weil.) 



A B C 0, area of cardiac flatness. 
A I K, area of cardiac dullness. 
C E, lower border of right lung. 
D F, lower border of left lung. 



G, H, upper borders of lungs. 

P Q, upper border of hepatic dullness. 

L M, lower border of hepatic flatness. 

N , lower border of stomach in moderate distention. 



Plate V. 




,m 



Percussion Borders on Left Side. (Weil.) 



A B, lower border of hepatic flatness. 
C D, lower border of left lung. 



E I L, splenic dullness. 

Q, lower border of stomach. 



Plate VI. 





6 SM 








Percussion Borders on Right Side. (Weil.) 

A B, lower border of the right lung. C D, lower border of hepatic flatness. 

E F, upper border of hepatic dullness. 



Plate VII. 




Percussion Borders on the Back. (Weil.) 

A B, upper border of lungs H I, K L, outer borders of the so-called renal dullness. 

C D , lower border of lungs. M N , lower borders of the lungs in deepest inspiration . 

E H, lower border of spleen. O P, shrinkage of upper border of lung in phthisis. 

K F. lower border of hepatic flatness. 



Pl*te VIII. 




dH --■ M 









> 










Percussion Borders in Childhood. (Weil.) 



ABCD, cardiac flatness. 
I G H, cardiac dullness. 



E C, F D, lower borders of the lungs. 
K, lower border of the liver. 



Plate IX. 




\ 



Percussion Borders in Old Age. (Weil.) 

A B C D, cardiac flatness. C E, D F, lower borders of the lungs. 

G H, cardiac dullness. M L, lower border of hepatic flatness. 

K, upper border of hepatic dullness. 



